Insecticide-treated bednets (ITNs) are one of the most effective means of malaria prevention, particularly among pregnant women and young children. However, ownership, regular use and appropriate maintenance of ITNs are uncommon in most malarious regions worldwide. This application's main objective is to evaluate the ability of microfinance to increase the use of ITNs and to decrease the burden of malaria in poor areas where existing markets and public health interventions have failed to ensure adequate population coverage. The four specific aims are the following: (1) To test the hypothesis that the offer of small loans for the purchase of ITNs and subsequent retreatment can lead to increased ITN ownership, even among very poor households. (2) To quantify the impact of the targeted loan offers on the prevalence of malaria as well as on hemoglobin levels for children under five (U5), pregnant women and other adults. (3) To understand better the specific roles of and the interplay between the economic and non- economic forces shaping health behavior in developing countries, by collecting detailed information on knowledge, perceptions and expectations about the health and monetary costs of malaria and ITN effectiveness. (4) To verify whether it is possible to induce high retreatment rates for bednets using particular micro-loan contracts designed to provide appropriate incentives to buyers. These aims will be achieved by implementing and evaluating a large-scale randomized trial in collaboration with a rural micro-lending organization in rural Orissa, a malaria-endemic state of India. The research plan consists of the following: firstly, a preliminary baseline survey has been conducted in 150 villages where the lender operates, followed by an information dissemination campaign about ITNs and malaria. A randomly-selected control group of 50 villages has not received further interventions. Free nets have been distributed to clients in a second randomly-selected group of 50 and clients from the remaining villages have be offered the choice between different loan contracts for the purchase of ITNs and retreatments. In fall 2008, a post-intervention survey will be conducted. Differences in take-up, retreatment rates, malaria and anemia prevalence and other health and socioeconomic outcomes will then be compared across different intervention groups. The collection of detailed information on knowledge, perceptions and expectations about the health and monetary costs of malaria and ITN effectiveness will also enable the construction of an explicit model of household behavior that rationalizes the observed choices. PUBLIC HEALTH RELEVANCE: Despite malaria being one of the world's deadliest infectious diseases, take up and usage of the leading prophylactic technology, insecticide-treated nets (ITNs), remains low in most malarious areas worldwide, including in the malaria-endemic Indian state of Orissa, where our project is located. Free or highly subsidized programs of ITN distribution as a public-health measure in developing countries are often hampered by funding constraints, but shifting the cost burden to consumers is likely to further reduce take up and create inequity in access for the poor. This research will use a randomized evaluation to test the viability of increasing ITN use with cost-recovery even among the very poor by providing ITNs on credit through a micro-finance network with an extended repayment period.